Transcript 5ADHDCDS_000

Externalizing Disorders
of Childhood
ADHD and Conduct Disorders
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Outline for each disease
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Brief Description
Prevalence/incidence
Case Study
DSM-IV Diagnostic Criteria
Etiology: causes and origins
Neuropathology: structural and functional effects
Other information
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Externalizing Disorders
 Childhood disorders involving overt breaking of
rules in multiple situations
 More prevalent in males than females
 Include a number of behavioural abnormalities
and academic impairments
 Disorders can have severe and long-lasting
consequences
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Attention Deficit/
Hyperactivity Disorder (ADHD)
Prevalence
 Common childhood disorder
 More prevalent in males than females (3:1)
 Prevalence: 3-5% of all school-aged children
 Stable developmental course - 50-60% of all
cases are noted by age 2-3 years
 Majority of cases not referred until school age for
behavioural reasons
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Case Study
 “David” was an 8 year old, third grade student
 Reading and math skills were one to two years below
grade level.
 He was failing every subject and seemed destined to
repeat a grade.
 His teachers described him as “disruptive” and
“oppositional” in class
 He had difficulty paying attention during structured and
unstructured activities.
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Case Study
 At home David was rebellious.
 His father had abandoned him virtually from birth.
 His mother, overwhelmed by the task of raising him and
his two sisters without espousal help, relapsed into drug
and alcohol abuse.
 She was frequently drunk and around David, she was
moody and volatile.
 He ran wild, going to bed late at night and failing to rise
for school in the morning.
 Intermittently he wet his bed.
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Case Study
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During the assessment:
David could only sit for a minute.
He described himself as dumb, but cool.
He hung out with older, rebellious students like himself to
compensate for his feelings of inadequacy.
He loved his mother but was struggling to maintain a
relationship with her.
He hated his father and wanted nothing to do with him.
With his grandparents he had a solid and positive
relationship, and he especially respected his grandfather.
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DSM-IV criteria
A. Either:
1. symptoms of inattention that have persisted
for at least 6 months
2. symptoms of hyperactivity-impulsivity that
have persisted for at least 6 months
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degree that is maladaptive and inconsistent with
developmental level.
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DSM-IV criteria
B. Some hyperactive-impulsive or inattentive
symptoms are present before 7 years of age.
C. Impairment is present in two or more settings.
D. Clear evidence of impairment in social,
academic, or occupational functioning.
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Types of ADHD
1. Combined type: if both attention and
hyperactivity/impulsivity criteria are met.
2. Inattentive type: attention criteria only.
3. Hyperactive–impulsive type:
hyperactive/impulsive criteria only.
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Etiology
1.
a)
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Genetic factors
Heredity
Higher risk if a parent has the disease
Higher rates in identical twins studies
b) Dopamine function
 Correlation with gene for dopamine transporter
gene (DAT1) for combined type
 Dopamine receptor (D4) in females with
combined type
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Etiology
2. Systemic, organic brain damage
 Hyperactivity due to brain damage caused by lack
of oxygen at birth (Tredgold, 1908).
 Flu and encephalitis epidemics of 1918: Children
later showed hyperactivity, distractibility,
irritability, deceptiveness, and were
unmanageable in school.
 Fetal/infant/childhood exposures: maternal
drinking or smoking during pregnancy, lead, etc.
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Other Information
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Comorbidities are common
Oppositional Defiant Disorder, Conduct Disorder
Poorer outcomes with comorbidity.
Social difficulties
50-60% experience rejection from peers
immature, uncooperative, self-centred, and
bossy.
few close friends, and tend to play with younger
children.
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Other Information
3. ADHD symptoms can persist well into
adolescence and adulthood.
 Outcome is poor particularly for hyperactiveimpulsive types: self-esteem, academic
achievement, problems with the law.
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Neuropathology
1. Frontal lobe circuits (mesocortical)
 Bilateral cortex, caudate and basal ganglia
 Deficit in delaying or inhibition of responses, not a
perceptual or performance deficit
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Disruption of monoamine transmitter systems
Based on treatment with stimulants
Mesolimbic (reward) pathways
Defective inhibitory system: increased activity and less
sensitivity to positive reinforcement
 Rewards work less effectively
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Neuropathology
3.
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Brain volume reduction
Particular reduction in frontal areas
Relation to response inhibition tasks (Wisconsin Card Sort)
May be the result of reduced monoamine metabolism in
these areas
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Conduct Disorder (CD)/
Oppositional Defiant Disorder (ODD)
 Pure externalizing disorder
 “Bad apples”, aggressive, disruptive, lawbreaking
 Lack of guilt or remorse for their actions
 Little effect of reinforcement or punishment
Prevalence
 Another very common reason for referral
 CD prevalence rates in males range from 6-16%;
females from 2-9%.
 ODD ranges from 2-16%, no gender differences
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Case Studies
 Brandon's teachers in the daycare center report
that he is the "terrorist of the 4- year-olds."
 He punches or bites children and pushes them off
the swings in the playground without
provocation.
 He swings the class pet rabbit by the tail in spite
of being told how it hurts the animal.
 His parents report that he has been difficult to
manage since he was an infant.
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Case Studies
 Robin, age 16: "When I was 13, that summer
was a blast. One time we picked up some older
guys in a bar and tried a new kind of speed. We
got really wild and we smashed in some car
windows and somebody called the police. My
mother freaked out and tried to punish me by
locking me in my room, but I would just skip out
on her through the window."
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DSM-IV Criteria for CD
 A repetitive and persistent pattern
 Basic rights of others or major age-appropriate societal
norms or rules are violated
 three or more of the following criteria :
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Aggression to people and animals
Destruction of property
Deceitfulness or theft
Serious violations of rules
The disturbance in behavior causes clinically significant
impairment in social, academic, or occupational functioning.
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Two Types of Conduct Disorder
1. Childhood Onset - occurs before age 10
• physical aggression
• disturbed peer relationships
• early oppositional or noncompliant behaviour
2. Adolescent-Onset - occurs after age 10
• less aggression and better peer relations
• poor peer group influences bad behaviour
 Childhood Onset more likely to have a poorer prognosis
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Gender: Behavioural Differences
Boys
Girls
aggression
lying
stealing
substance abuse
vandalism
running away
firesetting
sexual misconduct
(prostitution)
truancy
academic problems
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Neuropathology
1.
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XYY Syndrome in males
1:1000
extra Y chromosome may lead to aggression
higher rates of XYY cases in prison than in the general
population, property offenses in particular
 Dumb criminals? Lower intelligence (lower problem solving
ability) and apt to be caught
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Neuropathology
2. Low dopamine, crime and punishment
 motivated by a pathological need for stimulation
and reward seeking
 less sensitive to punishment effects
 Overactive Behavioural Activation System (Quay,
1988): compels them to seek rewards and thrills
 Underactive Behavioural Inhibition System: not
as anxious or worried about consequences
 Some support for this: Dopamine lower in frontal
lobes - PET (Raine, Lencz, & Scerbo, 1995).
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Other important information
 Inherent rejection of authority makes this a
difficult group to treat
 Must assure compliance before other changes are
implemented
 Social Learning and Behavioural Approaches
 Some treatment with barbiturates, Ritalin (if ADHD is
comorbid)
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Oppositional Defiant Disorder
 DSM-IV: if criteria for Conduct Disorder not met
 Pattern of defiant, angry, antagonistic, hostile,
irritable, or vindictive behavior
 Academic outcome better for ODD than CD
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